NAFLD: A PRIMARY CARE PERSPECTIVEGASTROENTEROLOGY, HEPATOLOGY, & NUTRITION NASPGHAN CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF NAFLD IN CHILDREN (2016) • Lifestyle

GASTROENTEROLOGY, HEPATOLOGY, & NUTRITION

Ryan Himes, MD

Section Head, Gastroenterology, Hepatology, & Nutrition

Medical Director, Pediatric Liver Transplant Program

NAFLD: A PRIMARY CARE PERSPECTIVE


• No relevant conflicts-of-interest

• Discussion of off-label use: none

DISCLOSURES


1. Terminology & natural history

2. Diagnosis of NAFLD in primary care

3. Treatment of NAFLD in primary care

OVERVIEW


• Know the difference in natural history between NAFL and NASH

• Recognize and apply to your practice the biology-based thresholds for serum ALT

• Be familiar with the NASPGHAN recommendations for diagnosis and treatment of NAFLD in children

OBJECTIVES


Terminology & Natural History


TERMINOLOGY

Nonalcoholic fatty liver (NAFL)

Nonalcoholic steatohepatitis (NASH)

Nonalcoholic fatty liver disease (NAFLD)


WHY DOES IT MATTER?


NAFLD is the most common chronic liver disease in children:

• 0.7% of 2-4 year olds

• 17.3% of 15-19 year olds

• 38% of obese children & adolescents

NAFLD IS HIGHLY PREVALENT

*Schwimmer et al, Pediatrics, 2006


• Among adults, NAFLD is the 2nd most common indication for liver transplantation*

• NAFLD is predicted to become the most common cause for liver transplantation within a decade

NAFLD IS ASSOCIATED WITH SIGNIFICANT MORBIDITY

*Wong et al, Gastroenterology, 2015


Diagnosis of NAFLD


• Highly prevalent condition

• Variable natural history

• Lack of biomarker to risk stratify

• No FDA-approved therapies

• Screening tools are imperfect

• Gold standard diagnostic test (liver biopsy) is costly and invasive

DIAGNOSTIC CHALLENGES IN NAFLD


• Active screening of asymptomatic, at-risk populations

• Incidental imaging findings suggestive of fatty liver

COMMON SCENARIOS IN PRIMARY CARE


1. Expert Committee Recommendations for Prevention, Assessment, & Treatment of Overweight & Obesity, Barlow (2007)

2. NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of NAFLD in Children (2016)

ACTIVE SCREENING


• Biennial screening, starting at age 10 years, for children:

• with BMI ≥95th percentile (obese)

OR

• with BMI 85th-94th percentile (overweight), who have other risk factors

• ALT > 2X ULN should prompt consultation with a pediatric gastroenterologist/hepatologist

1) EXPERT COMMITTEE RECOMMENDATIONS FOR PREVENTION, ASSESSMENT, & TREATMENT OF OVERWEIGHT & OBESITY, BARLOW (2007)


1. What constitutes a risk factor to determine which overweight children to screen?

2. What is meant by 2X ULN for ALT?

TWO IMPORTANT QUESTIONS…


RISK FACTORS FOR NAFLD

• T2DM

• Insulin resistance

• Dyslipidemia

• Elevated triglycerides

• Acanthosis nigricans

• Central adiposity

• Hypertension

• Obstructive Sleep Apnea

• Age ≥ 10 years

• Male gender

• Hispanic ethnicity

• Family history of NAFLD


WHAT IS MEANT BY 2X ULN FOR ALT?

Barlow’s paper uses 2X ULN and 60 U/L interchangeably…but the field has evolved!

Gastroenterology, 2010


• Survey 43 free-standing children’s hospitals in US

• Median ULN for ALT 52 U/L (range 30-90)

• Only 44% of hospitals used gender-specific norms

Gastroenterology, 2010


95th percentile for ALT (i.e. the ULN) was:

• 26 U/L for boys

• 22 U/L for girls


HOW DID 43 CHILDREN’S HOSPITALS MISS IT?


2. NASPGHAN CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF NAFLD IN CHILDREN (2016)

• Screening with ALT for NAFLD is appropriate for all obese children, and for overweight children with additional risk factors, beginning at age 9-11 years

• Interpretation of ALT should be based on biologically-derived upper limits of normal, and not individual laboratory ranges

• Persistently (> 3 months) elevated ALT, more than 2X ULN, should be evaluated for NAFLD, and other causes of chronic hepatitis


2. NASPGHAN CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF NAFLD IN CHILDREN

• ALT >80 U/L warrants increased clinical concern and timely evaluation, as the likelihood of significant liver disease is higher

• Routine ultrasound is not recommended as a screening test for NAFLD in children due to low sensitivity and specificity

26 52 80Boys

22 44 80Girls 44


LIMITATIONS OF STANDARD US-BASED SCREENING FOR FATTY LIVER

• Trans-abdominal US doesn’t do a good job of picking up liver fat when < 33%

• fatty liver is defined as >5% steatosis

• PPV of US to detect steatosis: 47-62%*

• Poor concordance between grade of steatosis by US compared to histology or MRI

*Schwimmer, Hepatology, 2016


NAFLD SCREENING SUMMARY RECOMMENDATION


INCIDENTAL IMAGING FINDING SUGGESTIVE OF FATTY LIVER

Normal Increased hepatic echogenicity


INCIDENTAL IMAGING FINDING SUGGESTIVE OF FATTY LIVER

• No pediatric data to guide decision-making


FOLLOW-UP OF INCIDENTAL IMAGING FINDINGS


Treatment of NAFLD


NAFLD TREATMENT ENDPOINTS

• Gold standard: regression of NAFLD (e.g. steatosis, inflammation, and/or fibrosis)

• Silver: resolution of NASH (i.e. inflammation)

• Bronze: “sustained ALT decrease from baseline, particularly if durable (i.e. > 1 year) is a reasonable surrogate for response to treatment”

Vos et al, JPGN, 2016


THERAPEUTIC CHALLENGES

• No FDA-approved therapies for NAFLD

• With 2 notable exceptions, pediatric NAFLD trials have been small, unblinded, non-randomized, of short duration…

• Weight reduction is highly effective, but practically, very difficult to achieve and sustain


• 173 participants age 8-17 yrs with bx-confirmed NAFLD

• 800 IU vitamin E vs. 1000 mg metformin vs. placebo over 96 weeks

• Primary outcome: ALT ≤ 50% baseline b/t weeks 48-96

• Secondary outcome: liver histology

Lavine et al, on behalf of the NASH CRN, JAMA, April 2011


TONIC RESULTS

• Primary outcome:

• Secondary outcomes:Placebo Vitamin E Metformin

Hepatocyte ballooning 0.1 -0.5* -0.3*

NAS score -0.7 -1.8* -1.1

Resolution of NASH 28% 58%* 41%

Placebo Vitamin E Metformin

Sustained reduction ALT 17% 26% 16%

Mean ALT change from baseline -35.2 U/L -48.3 U/L -41.7 U/L


• 169 participants age 8-17 yrs with bx-confirmed NAFLD

• Cysteamine bitartrate (CB) vs. placebo over 52 weeks

• Primary outcome: liver histology

• Secondary outcome: change in ALT from baseline

Schwimmer et al, on behalf of the NASH CRN, Gastroenterology, December 2016


CYNCH RESULTS

• Primary outcome:

• Secondary outcomes:Placebo CB

Mean reduction in ALT from baseline -8 U/L -53 U/L*

Reduction in lobular inflammation 21% 36%*

Placebo CB

Improved histology at 52 weeks(decreased NAS score and no

worsening of fibrosis)28% 22%


NASPGHAN CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF NAFLD IN CHILDREN (2016)

• “No currently available medications or supplements are recommended to treat NAFLD, because none have been proven to benefit the majority of NAFLD patients.”


WHAT DOES WORK: WEIGHT LOSS

Fibrosis

NASH resolution

Ballooning/Inflammation

Steatosis

Adapted from Stephen Harrison, AASLD 2015

Weight loss ~3%

Weight loss ≥10%

Weight loss ≥7%

Weight loss ≥5%


NASPGHAN CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF NAFLD IN CHILDREN (2016)

• Lifestyle modification to improve diet & increase physical activity are the 1st line therapy for all children with NAFLD

• Avoidance of sugar-sweetened beverages is suggested as a strategy to decrease adiposity

• Increasing moderate to high intensity physical activity and limiting screen time to < 2 hours/day is recommended for all children, including those with NAFLD


OUR APPROACH

• Involve RD early and often

• Sugary drink elimination is the first goal

• Provide specific, written (or illustrated) instructions, for diet & exercise

• Utilize local resources

• YMCA, insurance, hospitals, rec centers


OUR APPROACH

• Set an achievable initial goal for weight reduction

• Program regular face time/accountability checks

• Doesn’t necessarily have to be an MD/NP/PA

• Elicit family support/partnership


REMEMBER TO SET A GOOD EXAMPLE!


GOOD NEWS AHEAD…

Agent Mechanism

GFT-505 PPAR agonist

OCA FXR agonist

Cenicriviroc CCR2/CCL5 antagonist

Simtizumab LOXL2 antagonist

Bovine colostrum T-reg induction

Emricasan Caspase inhibitor

Aramchol Synthetic fatty acid

GR-MD-02 Galectin-3 inhibitor

BMS986036 Recombinant FGF-21

Adapted from Stephen Harrison, AASLD 2015


KEY REFERENCES• Expert committee recommendations regarding the prevention, assessment, and treatment of child and adolescent overweight and obesity: summary report.

Barlow SE; Expert Committee. Pediatrics. 2007 Dec;120 Suppl 4:S164-92.

• NASPGHAN Clinical Practice Guideline for the Diagnosis and Treatment of Nonalcoholic Fatty Liver Disease in Children. Vos MB, Abrams SH, Barlow SE, Caprio S, Daniels SR, Kohli R, Mouzaki M, Sathya P, Schwimmer JB, Sundaram SS, Xanthakos SA. J Pediatr Gastroenterol Nutr. 2016 Nov 30.

• SAFETY study: alanine aminotransferase cutoff values are set too high for reliable detection of pediatric chronic liver disease.Schwimmer JB, Dunn W, Norman GJ, Pardee PE, Middleton MS, Kerkar N, Sirlin CB. Gastroenterology. 2010 Apr;138(4):1357-64, 1364.e1-2. doi: 10.1053/j.gastro.2009.12.052.

• Effect of vitamin E or metformin for treatment of nonalcoholic fatty liver disease in children and adolescents: the TONIC randomized controlled trial. Lavine JE, Schwimmer JB, Van Natta ML, Molleston JP, Murray KF, Rosenthal P, Abrams SH, Scheimann AO, Sanyal AJ, Chalasani N, Tonascia J, Ünalp A, Clark JM, Brunt EM, Kleiner DE, Hoofnagle JH, Robuck PR; Nonalcoholic Steatohepatitis Clinical Research Network. JAMA. 2011 Apr 27;305(16):1659-68. doi: 10.1001/jama.2011.520.

• In Children With Nonalcoholic Fatty Liver Disease, Cysteamine Bitartrate Delayed Release Improves Liver Enzymes but Does Not Reduce Disease Activity Scores. Schwimmer JB, Lavine JE, Wilson LA, Neuschwander-Tetri BA, Xanthakos SA, Kohli R, Barlow SE, Vos MB, Karpen SJ, Molleston JP, Whitington PF, Rosenthal P, Jain AK, Murray KF, Brunt EM, Kleiner DE, Van Natta ML, Clark JM, Tonascia J, Doo E; NASH CRN. Gastroenterology. 2016 Dec;151(6):1141-1154.e9. doi: 10.1053/j.gastro.2016.08.027.


Ryan Himes, M.D.

Ochsner Children’s Liver Program

[email protected]

Cell 713-882-0032

Documents

NAFLD: A PRIMARY CARE PERSPECTIVEGASTROENTEROLOGY, HEPATOLOGY, & NUTRITION NASPGHAN CLINICAL PRACTICE GUIDELINE FOR THE DIAGNOSIS AND TREATMENT OF NAFLD IN CHILDREN (2016) • Lifestyle